DEBBY B. HOUSTON, CMA(AAMA), CPC

BILLING OUTREACH EDUCATOR, UVA

PHYSICIANS GROUP

ICD-10 UPDATE

ICD- 10

• Will it be here on October 1, 2013

•Or NOT

DOCUMENTATION AND THE ELECTRONIC MEDICAL RECORD

Objectives

• ICD-10-CM Regulatory Environment• ICD-9-CM vs. ICD-10-CM• ICD-10-CM Draft Guidelines for Coding and

Reporting 2011• Documentation Challenges• Electronic Medical Record (EMR)• Failure to Implement• Opportunities• How To Prepare

ICD-9 TO ICD-10

NOW

• CH 1 Infectious and Parasitic Diseases 001-139

• CH 2 Neoplasms 140-239

• CH 3 Endocrine, Nutritional and Metabolic Diseases

• and Immunity Disorders 240-279• CH 4 Diseases of the Blood and Blood-forming

Organs 280-289• CH 5 Mental Disorders 290-319

• CH 6 Diseases of Nervous System and Sense Organs 320-389

• CH 7 Diseases of the Circulatory System 390-459 • CH 8 Diseases of the Respiratory System 460-

519

THEN

• Certain infectious and parasitic diseases A00-B99

Neoplasms C00-D499

Diseases of the Blood and Blood-forming Organs D50- D89 Endocrine, Nutritional and Metabolic Diseases E00-E89 Mental and Behavioral Disorders F01-F99 Diseases of the Nervous System G00-G99

Diseases of the Eye and Adnexa (new) H00-H59

Diseases of the Ear and Mastoid Process (new) H60-H95

ICD-9 TO ICD-10

NOW• CH 9 Diseases of the Digestive System 520-579

• CH 10 Diseases of the Genitourinary System 580-629

• CH 11 Complications of Pregnancy, Childbirth and the Puerperium 630-679

• CH 12 Diseases of the Skin and Subcutaneous Tissue 680-709

• CH 13 Diseases of Musculoskeletal and Connective Tissue 710-739

• CH 14 Congenital Anomalies 740-759 • CH 15 Newborn (Perinatal) Guidelines 760-779

• CH 16 Signs, Symptoms and ILL-Defined Conditions 780-799

THEN• Diseases of the Circulatory System I00-I99

• Diseases of the Respiratory System J00-J99

• Diseases of the Digestive K00-K94

• Diseases of the Skin and Subcutaneous Tissue L00-L99

• Diseases of the Musculoskeletal System and Connective Tissue M00-M99

• Diseases of the Genitourinary System N00-N99• Pregnancy, Childbirth and the Puerperium O00-

O9a

• Certain Conditions Originating in the Perinatal Period P05-P96

ICD-9 TO ICD-10

NOW• CH 17 Injury and Poisoning 800-999

• CH 18 N/A –

• CH 19 N/A –

• CH 20 N/A – • CH 21 N/A –

• Index

• Neoplasm Table • Table of Drugs and Chemicals – • Index to External Causes -• Classification of Factors influencing Health Status

and Contact with Health Service V01-V89

• Supplemental Classification of External Causes of Injury and Poisoning E800-E999

THEN• Congenital Malformations, Deformations and

Chromosonal Abnormalities Q00-Q99• Symptoms, Signs and Abnormal Clinical and

Laboratory Findings R00-R99• Injury, Poisoning and Certain Other

Consequences of External Causes S00-T88• External Causes of Morbidity (new) V00-Y99

• Factors Influencing Health Status and Contact with Health Services (new) Z00-Z99

• Index• Neoplasm Table• - Table of Drugs and Chemicals• Index to External Causes

ICD-9-CM VS ICD-10-CM

ICD-9-CM ICD-10-CM

17 Chapters 21 Chapters

E and V code Supplemental Classification

All codes are alphanumeric

Sense organ conditions in Nervous System

Separate Chapters

Outdated language Current terminology

Injuries by type Injuries group by site , then type

Complications of Medical care in 1 Chapter

Complications have been categorized to procedure-specific body system chapters

Maximum of 5 characters Maximum of 7 characters

Partial code titles Full code titles

Code extensors for specificity and laterality

Dummy place holder (x)

ICD-10-CM STRUCTURAL CHANGES

ICD-9-CM ICD-10-CM

3-5 characters 3- 7 characters

First character is numeric or alpha (E or V)

First character is alpha

Characters 2-5 are numeric All letters except U

Always at least 3 characters Characters 2-7 are alpha or numeric

Use of decimal after 3 characters Use of decimal after 3 characters

13,000 codes 72,000 codes (approximately)

S

ICD-10-CM FORMAT

5 . 7 0 12

CategoryChronic heart disease Atherosclerosis of coronary artery bypass

graft(s), complication, manifestation

Atherosclerosis of coronary bypass graft(s), unspecified, with angina pectoris with documented spasm

I

GENERAL CODING GUIDELINES FOR 2011

For reporting purposes only codes are permissible not categories, subcategories. The 7th character is applicable when required.

Place holder “x” is used as a placeholder on certain codes to allow for future expansion of the code. Example: poisoning, adverse effect, and underdosing codes (T36-T50) may need a placeholder to be considered a valid code.

7th Character – The 7th character must always be the 7th character in the data field. If a code that requires a 7th character is not 6 characters, then a place holder must be used to fill in the empty characters.

•“NEC”- still represents not elsewhere classifiable in the Alphabetical Index.• NOS – still represents not other wise specified and is the equivalent of unspecified in the Alphabetic Index.

•“NEC” still represents not elsewhere classifiable in the Tabular list.• NOS still represents not otherwise specified and is the equivalent of unspecified in the Tabular List

GENERAL CODING GUIDELINES

Locating a code- Locate a code in the Alphabetical Index and verify the code in the Tabular list.Apply instructional notes that appear in both the Alphabetical Index and the Tabular List. (same)

Level of detail in Coding- Codes must be reported to the highest level of detail. Codes from A00 – T88.9, Z00-Z99 - must be used to identify diagnosis, symptoms conditions, problems, complaints, or other reason(s) for a encounter/visit. (same)

Signs and symptoms – signs and symptoms must be reported when a related definitive diagnosis has not be established by the provider. (same)

Conditions that are integral part of a disease process – signs and symptoms that are routinely associated with a disease process should not be coded, unless otherwise instructed by the classification. (same)

Laterality – for bilateral sites the sites the final character of the code in ICD-10-CM indicates laterality. If no bilateral code is provided, and the condition is bilateral then assign separate codes for both the left and the right side (new).

Combination code - is a single code used to classify: - Two diagnoses, or a diagnosis with an associated secondary process (manifestation - A diagnosis with an associated complication (new)

DIAGNOSTIC CODING AND REPORTING GUIDELINES FOR OUTPATIENT SERVICES

Selection of first listed diagnosis – Coding conventions of ICD-10-CM as well as general disease

specific guidelines take precedence over the outpatient guidelines.

Codes from A00 – T88.9, Z00-Z99 - must be used to identify diagnosis, symptoms conditions,

problems, complaints, or other reason(s) for a encounter/visit.

Accurate reporting of ICD-10-CM diagnosis codes – Documentation should describe the patient’s condition using terminology which includes specific diagnoses as well as

symptoms, problems, or reason for the encounter.

Factors influencing health status – Z00- Z99 are provided to deal with occasions when circumstances other than a disease or injury are recorded as diagnosis or problems.

Level of detail in Coding – ICD-10-CM codes are 3,4,5,6 or 7 characters. Codes with three

characters are head of a category codes. Subdivided by the use of fourth, fifth, sixth, or seventh

characters to provide greater specificity. A code is not valid if it has not been coded to the full number of

characters required for that code, including the 7th character extension, if applicable.

ICD-9-CM VS ICD-10-CM

ICD-9-CM ICD-10-CM

305.0 Nondependent alcohol abuse 305.00 Nondependent alcohol abuse, unspecified drunkenness 305.1 Nondependent alcohol abuse, continuous drunkenness 305.2 Nondependent alcohol abuse, episodic drunkenness 305.03 Nondependent alcohol abuse, in remission

F 10.12 Alcohol abuse with intoxication F10.120 Alcohol abuse with intoxication, uncomplicated F10.121 Alcohol abuse with intoxication delirium F10.129 Alcohol abuse with intoxication, unspecified

• Y 90.0 Blood alcohol level less than 20mg/100ml

• Y90.1 Blood alcohol level of 20-39 mg/100ml

• Y90.2 Blood alcohol level of 40-59 mg/100 ml

• Y90.3 Blood alcohol level of 60-79 mg/100ml

• Y90.4 Blood alcohol level of 80-99 mg/100 ml

• Y 90.5 Blood alcohol level of 100- 119 mg/100ml

• Y90.6 Blood alcohol level of 120-199 mg/100ml

• Y90.7 Blood alcohol of 200-239 mg/100ml

• Y90.8 Blood alcohol level of 240 mg/100ml

• Y90.9 Presence of alcohol in blood, level not

specified

Y90.-Evidence of alcohol involvement determined by blood alcohol. Code first any associated alcohol related disorders.

ICD-10-CM

DOCUMENTATION CHALLENGE

Reason for visit : Follow-up- Nephrology

Progress Note: __________is a 87 y.o. male who presents for follow-up of chronic kidney disease stage 3. It appears that he developed sudden onset of shortness of breath after seeing me and was hospitalized for a few days with CHF exacerbation and pneumonia. Since then he has been doing better.

ROS (Review of Systems) •Review of Systems •Constitutional: Positive for malaise/fatigue. Negative for fever, chills and weight loss. •Mostly on a wheel chair •Eyes: Negative for blurred vision. •Cardiovascular: Positive for leg swelling. Negative for chest pain and palpitations. •Continues to have dyspnea on exertion •Gastrointestinal: Negative for nausea, vomiting and diarrhea. •Genitourinary: Negative for dysuria and hematuria. •Skin: Negative for rash. •Neurological: Negative for weakness and headaches. •Psychiatric/Behavioral: The patient does not have insomnia. •All other systems reviewed and are negativePhysical Exam•Nursing note and vitals reviewed. •Constitutional: He is oriented to person, place, and time and well-developed, well-nourished, and in no distress. No distress. On a wheel chair and in no distress. Normal speech, on oxygen •HENT: •Mouth/Throat: Oropharynx is clear and moist. •Eyes: Conjunctivae and EOM are normal. •Neck:

DOCUMENTATION CHALLENGE

• Not able to assess JVD as he was sitting up in his wheel chair during the exam • Cardiovascular: Regular rhythm, normal heart sounds and intact distal pulses. Exam reveals

no gallop and no friction rub. • No murmur heard. • Pulmonary/Chest: Effort normal and breath sounds normal. No respiratory distress. He has no

wheezes. Few crackles left lung base

• Abdominal: Soft. Bowel sounds are normal. He exhibits no mass. No tenderness. He has no rebound and no guarding. Musculoskeletal: Normal range of motion. He exhibits edema. He exhibits no tenderness. 1+ bilateral lower extremity edema Lymphadenopathy: He has no cervical adenopathy. Neurological: He is alert and oriented to person, place, and time. Gait normal.

• Skin: No rash noted. No erythemaAssessment & Plan

• Chronic Kidney Disease stage 3 with episodes of AKI secondary to ischemic nephropathy and possibly hypertension . According to him his renal function was checked a month ago at his PCP's office and he was told it was better. I will check renal function again.

• No proteinuria or even microalbuminuria . • Secondary hyperparathyroidism of renal origin. Patient is being treated with vitamin D. I will

check PTH, phosphorus and calcium today. • Anemia of chronic kidney disease. Hemoglobin has been was below the goal of 10 - 12 g/dL

for CKD. I will check a CBC today. He may benefit from treatment with ESA. • Blood pressure. Patients blood pressure ( 131/60 ) is within the desired goal of <130/80 for

CKD. • Volume status. The patient appears to be hypervolemic but better than his last visit. His

lungs sounded better and edema is less. He is now on Bumetanide. I did not change the dose.

• Discussed health maintenance, including regular aerobic exercise, low fat/low salt diet, and periodic exams.

• Return to Clinic in 6 months and as needed. Patient has issues with transportation and stated that it costs him a lot of money to come and see me. I left the decision regarding future appointments.

DOCUMENTATION CHALLENGE

Addendum: Hyperkalemia has resolved. No microalbuminuria, normal vitamin D level. PTH remains unchanged and not too high for degree of renal function. He remains anemic, but no indication for treatment with ESA. I suggest checking his iron stores.

Visit Diagnoses and Associated Orders:

•Chronic kidney disease, stage III (moderate) [585.3]•Secondary hyperparathyroidism (of renal origin) [588.81]•Hypertensive kidney disease with chronic kidney disease stage III [403.90BK]•Congestive heart failure, unspecified [428.0]

DOCUMENTATION CHALLENGE

Chronic Kidney Disease , stage III

Chronic kidney disease, stage III (N18.3)

Secondary hyperparathyroidism

Secondary hyperparathyroidism ( N25.81)

Anemia of chronic disease

Hypertensive kidney disease with chronic kidney disease stage III ( I12.9)

Congestive heart failure, (150.9)

Documentation must validate the codes assigned

Assessment & Plan

Visit Diagnoses

DOCUMENTATION CHALLENGE

Issues:

•The CHF was mentioned in the HPI, but was not documented and addressed in the Assessment and Plan.

•The CHF was not specified

•Anemia of chronic kidney disease is not listed in the visit diagnoses section in the EMR.

•Are the codes sequenced appropriately?

Actions:

•Coding guidelines state that chronic conditions that are addressed during the encounter should be coded. Coding Professional (CP) should contact provider about clinical significance of CHF.

•Anemia of chronic kidney disease needs to be added to the list of visit diagnoses.

•Codes should be sequenced in accordance with coding guidelines.

DOCUMENTATION CHALLENGE

Documentation issues are resolved:

CP contacts the provider and CHF is added to the assessment and plan. The provider documents that the patient has chronic systolic heart failure. Anemia of chronic kidney disease is added to the visit diagnoses list

Visit diagnoses for this encounter have been revised:

1.I12.9 – Hypertensive chronic kidney disease, with stage 1-4 chronic kidney disease, or unspec CKD2.N18.3 – Chronic kidney disease, stage III (moderate)3.I50.22 - Chronic systolic congestive heart failure4.N25.1 - Hyperparathyroidism5.D63.1 – Anemia in chronic kidney disease

FAILURE TO IMPLEMENT

Failure to successfully implement ICD-10-CM:

Potential to create distorted or misinterpreted information about patient care

Impacts decisions to improve healthcare deliveryCreates coding and billing backlogIncreases in claims rejections/denialsCauses cash flow delaysPlaces payer contracts and/or market share

arrangements at risk due to poor quality rating or higher costs

OPPORTUNITIES

• IT coupled with the adoption of ICD-10-CM can effect the quality, effectiveness, and delivery of health care services

• The classification requires front-end documentation improvement of medical information

• Significant shift in delivery and finance

• Development of EHR components

HOW TO PREPARE

Assess ICD-10-CM readiness

Evaluate documentation requirements

Improve documentation

HOW TO PREPARE

Centers for Disease Control and Prevention

http://www.cdc.gov/nchs/icd/icd10cm.htm#10update

Centers for Medicare and Medicaid http://www.cms.gov/ICD10/12_2010_ICD_10_CM.asp

THANK YOU!!!!!

QUESTIONS???